U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter XI

Contents

CHAPTER XI

THE DIVISION OF LABORATORIES AND INFECTIOUS DISEASES
(Continued)

THE SECTION OF LABORATORIES;a TECHNICAL WORK OF LABORATORIES

THE SECTION OF LABORATORIES

The laboratory section of the division of laboratories was distinct from the central laboratory, but closely connected with it.1 Its headquarters at Dijon exercised technical supervision over the Medical Department laboratories throughout the American Expeditionary Forces, and was charged with their inspection and supply, the pathological service of the American Expeditionary Forces, special research, the collection of museum specimens, photographs, and other art records of medical department activities, cooperation with the water supply and gas defense services, and the destruction of rodents.1

From the viewpoint of the nature of their activities, the laboratories of the American Expeditionary Forces were divisible into two general types which were comparable, respectively, to the laboratories which served boards of health in civil communities, and those which served hospitals.1

The base laboratories located in the sections of the Services of Supply, and the mobile units attached to armies and the divisional units were concerned mainly in the control and prevention of transmissible diseases, while the principal activities of all other units were similar to those carried on in laboratories pertaining to the larger and better hospitals in civil communities in the United States.1

Also, from the viewpoint of equipment, the laboratories of the American Expeditionary Forces could be classified into two general categories: Stationary or mobile.1 The equipment furnished the stationary units was quite similar to that used in hospitals in civil communities in the United States though in some respects it was not so elaborate. For example, provision of apparatus for blood chemistry was considered but was excluded because of its very questionable practical importance under war conditions.1 On the other hand, the equipment furnished laboratory units attached to the headquarters of the armies, to evacuation and mobile hospitals, and to divisions was packed in special chests to facilitate transport. These units were constantly moving from place to place as the zone of battle activity shifted from one section to another.1

The general laboratory system for the American Expeditionary Forces is shown diagrammatically in Figure 8.

As shown by Table 4, 278 laboratories conforming to the different types outlined above were in the service of the American Expeditionary Forces on November 11, 1918, the date the armistice was signed. 1

aThe Medical Department laboratories which did not pertain to the division of laboratories of the chief surgeon's office are discussed in other chapters of this volume. Thus the dental laboratory is discussed under the chapter pertaining to dental division of the chief surgeon's office.


168

TABLE 4.-Types and numbers of laboratories in operation in the American Expeditionary Forces, May, 1917, to April, 19191

1917

1918

1919

 

May

June

July

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

Apr

Central Medical Department laboratory

---

---

---

---

---

---

---

---

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Base laboratories, sections of Services of Supplya

---

---

1

1

1

1

1

1

3

3

5

5

7

7

7

7

10

10

10

10

9

9

8

8

Base laboratories, in hospital centers (included in next line)

---

---

---

---

---

---

---

---

1

1

1

2

2

5

7

11

14

16

17

17

11

9

9

8

Base hospital laboratories

---

1

5

7

7

8

9

13

14

15

19

20

25

33

47

57

84

87

112

112

82

66

47

45

Camp hospital laboratories

---

---

---

---

---

1

2

3

3

4

24

24

25

25

33

33

42

45

51

56

63

58

61

59

Evacuation hospital laboratories

---

---

---

---

---

---

---

---

3

3

3

4

8

8

8

12

23

25

37

37

24

20

9

18

Mobile hospital laboratories

---

---

---

---

---

---

---

---

---

---

---

---

1

2

3

5

7

10

12

13

3

5

4

1

American Red Cross hospital laboratories

3

3

3

3

3

3

3

3

3

3

4

4

4

8

15

18

18

19

19

19

14

12

9

8

Division laboratories

---

---

---

---

---

---

---

---

3

3

4

5

6

8

14

21

33

35

36

36

28

21

16

13

Total

3

4

9

11

11

13

15

20

30

32

60

63

77

92

128

154

218

232

278

284

224

192

155

153

Base hospitals with British

3

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

3

1

1

1

aIn this table Army Laboratory No. 1 is listed as a base section laboratory.

FIG. 8.-Diagram showing types of laboratories in the American Expeditionary Forces

INSPECTION OF LABORATORIES

In January, 1918, certain officers of the laboratory service made a hurried visit of inspection to the then existing centers of activity of the American Expeditionary Forces, in order to acquire first-hand knowledge of the laboratory personnel and equipment then available, to inspect available sites for the


169

establishment of base laboratories in the sections of the Services of Supply and to expedite the organization and development of those units.1 This was the beginning of a system of general inspection which later was actively developed.1 This inspection service was under the charge of the officer commanding the central laboratory, but it was quite impossible for him to cover more than a small part of this phase of the work alone and at the same time perform his other duties. When new areas were to be occupied by the American Expeditionary Forces or new projects were contemplated, that officer visited the area concerned and after consultation with its senior medical officer, made a survey of the general situation from the viewpoint of laboratory requirements, conferred concerning the latter's recommendation, and submitted a report to the director of laboratories covering the situation, with recommendations to meet it.1 When the director, or other officer, returned from a trip of inspection a conference was held and verbal reports were made, followed by a written report that was circulated in the office of the director of the division.1

This inspection service gave the director and his assistants an infinitely better conception of existing conditions than could have been obtained otherwise, resulted in a much higher degree of coordination in the laboratory service at large, and enabled the director on many occasions to make decisions of much greater value to the service than would have been possible had this system of inspection not been in force.1

STATIONARY LABORATORIES

BASE LABORATORIES ASSIGNED TO SECTIONS OF THE SERVICES OF SUPPLY

In accordance with the original plan of organization one base laboratory was established for each section or other subdivision of the Services of Supply.1 These units were under the direct control of the section surgeon and were located at the headquarters of each section, except that the laboratory for the intermediate section was at Tours, that for the advance section at Neufchateau, and that for base section No. 3, at Winchester, England. These base laboratories occupied permanent buildings and were completely equipped for general laboratory work, affording general and special laboratory facilities for troops in the section who were not served by other laboratories.1

Their activities consisted of clinical examinations, general and special bacteriology, general and special serological work, the distribution of culture media, laboratory examinations of water supplies, the investigation of outbreaks of epidemic diseases and such other activities as the section surgeon deemed advisable.1 They were established as rapidly as the necessity for them arose and personnel and equipment became available.1 The first unit of this type, Army laboratory No. 1, was established as mentioned above, at Neufchateau, in September, 1917, and the last at Le Havre, in September, 1918, where it served Base Section No. 4. By that time a laboratory of this type was operating in each section or other subdivision of the Services of Supply.1

In the original plan of organization for these units provision was made for the transportation necessary to carry out field surveys of water supplies, to investigate outbreaks of epidemic diseases and to forward therapeutic sera


170

emergencies, but the transportation problem in the American Expeditionary Forces was of such a nature that vehicles were not always available for the effective prosecution of these duties throughout the areas they sought to serve.1

The following brief history of the base laboratory for Base Section No. 5 is illustrative, to a degree, of those of other sections of the Services of Supply.

BASE LABORATORY, BASE SECTION NO. 5

This laboratory was organized in February, 1918, under the title of stationary laboratory No. 2.2 This occurred in Washington, D. C., where the various officers and men connected with it assembled and remained on duty until their departure for France, May 1, 1918. On arrival in France there were no available supplies for the laboratory, those originally shipped having failed to arrive, and substitutes were extremely difficult to procure. These defects, however, were gradually overcome.2 Shortly after its arrival in this section the name of the laboratory was changed to base laboratory, base section No. 5, under which title it continued to operate.2 It gradually developed into a concrete organization so staffed and equipped that practically any type of laboratory diagnosis or research could be performed.2 Its greatest activities were the study and control of infectious diseases in base section No. 5.

About June 12, 1918, the base laboratory absorbed that of Camp Hospital No. 33, whose premises it occupied and enlarged to four rooms. Permanent fixtures were installed, but six weeks later, when other quarters became available, the base laboratory left this location, which was reoccupied by the laboratory of Camp Hospital No. 33.3 In August, 1918, the base laboratory was installed completely equipped in a house in Brest, formerly a private residence, but which lent itself well for the purposes.2

In the organization of this unit various departments were created, each in charge of the officer best qualified for that particular work. As far as possible these departments were kept strictly separated that their work might be unhampered by the necessity of their respective personnel undertaking other work for which they were less qualified.2 The departments consisted of office and records, property, bacteriology, pathology and serology, chemistry, and water control. In the investigation of infectious diseases in this base section the laboratory was entirely dependent upon the activities of its own personnel to secure specimens for examination.2 The respiratory infections which swept through base section No. 5 in the fall and winter of 1918 were studied by the bacteriological and pathological departments. Cultures were made from the sputum and the various organs at autopsy. All organisms secured were carefully typed and, when possible, preserved for future study. The bacteriological and pathological work done in common with these diseases was of an advanced and extremely thorough character. All this work was done under the direct supervision and at the direction of the base surgeon base section No. 5.

Complete liaison, both official and unofficial, existed between this organization, the local hospitals, and the Engineer Corps.2 Most of the laboratory activities pertained to the service of these agencies. The chief association with the engineers related to the water supply of Brest, and that with hospitals to the control of infectious diseases.2


171

In addition to the duty indicated above this organization exercised a general control and supervision over the smaller laboratories attached to hospitals in and about Brest, and in a way served as a supply depot not only for laboratory material but also for therapeutic and diagnostic sera.2 The therapeutic sera were secured by requisition, as were some of the diagnostic sera, but most of the former were prepared by the department of bacteriology connected with the base laboratory.2 Hospitals in the vicinity were supplied sera on requisition by means of the light truck above mentioned. All trans-Atlantic transports requiring sera were supplied in like manner on telephonic request that was later confirmed in writing. Because of the fact that they were frequently demanded in emergencies, these supplies were sent out day or night, for the laboratory operated throughout the 24 hours of the day.2

A great handicap, which this laboratory experienced and which caused marked detriment to complete efficiency, was inadequate transportation.

After great difficulties this laboratory secured a light truck, which alone made it possible for its personnel to cover much ground and secure the specimens requested in connection with the control of infectious diseases.2 The one vehicle permanently supplied was not sufficient to meet the demands, and the procurement of other transportation from the Motor Transportation Corps was very uncertain and inadequate. This feature caused much loss of valuable material and time. Another handicap was the fact that supplies were limited, for it was always difficult and sometimes impossible to obtain them.2

BASE LABORATORIES FOR HOSPITAL CENTERS, AND HOSPITAL LABORATORIES SERVING IN CENTERS

Plans for the organization of the laboratory service had considered the conservation of personnel, equipment, supplies, and construction, in order to release tonnage and to utilize resources to the best advantage.1 In the laboratory service of the large hospital centers which were made up of several base hospital units great economies were thus effected. Each base hospital included in its personnel two or more commissioned laboratory officers, a varying number of enlisted technicians, and a complete laboratory equipment. By centralization of the laboratory service the efficiency was increased, personnel released, equipment conserved, and construction diminished.1 Therefore, in each hospital center one base laboratory for the entire service of the center was organized and one small clinical laboratory established for each base hospital unit. The laboratory for the center was part of the headquarters organization, and its commanding officer the representative of the commanding officer of the center in all matters relating to the laboratory service. Its personnel consisted of selected officers and enlisted technicians drawn from the hospital units comprising the center; its equipment was drawn from the same sources.1

Standard plans for the laboratory buildings for the centers and for smaller clinical laboratory buildings for each unit were prepared in the office of the director of laboratories, A. E. F., and turned over to the hospitalization division of the chief surgeon's office for inclusion in the general plans of construction.1 The original plans provided for two standard barracks for the base laboratory and one small building for each hospital unit functioning in the center, but the


172

accommodations for the base laboratory were later reduced to one building because of scarcity of materials.1

The base laboratory for the center in general performed such routine clinical and pathological work as might be necessary, all highly technical bacteriological and serological work for the center, and prepared culture media and special reagents, which it issued to the subsidiary clinical laboratories.1 Those organizations operating in the several base hospital units composing the center carried on the clinico-pathologic work for their respective units. 1

The general method outlined above was that followed in the large hospital centers of temporary construction.4 In the large centers which utilized permanent buildings that were a considerable distance apart it was not always possible to centralize the work so definitely.4 However, by November, 1918, a laboratory service which conformed in general to the method outlined above had been established in all hospital centers operating in the American Expeditionary Forces.4

In those hospital centers where permanent buildings were utilized the laboratory services were housed in such rooms or buildings as were found most suitable for their purposes without extensive alterations.5 The laboratories, therefore, at these centers varied considerably in size and character, ranging in size, for example, from a temporary wooden building erected for laboratory work at the hospital center at Limoges to an entire hotel quipped for laboratory purposes at the hospital center at Vichy.5

At all the hospital centers except that at Vichy the laboratory work was organized in conformity with Memorandum No. 8, July 23, 1918, division of laboratories and infectious diseases.5 As this memorandum is reproduced in the appendix it is sufficient here to state that it provided for a laboratory officer who, as a member of the staff of the commanding officer of the center, would exercise control over its entire service, in so far as his specialty was concerned, and for the establishment of a center laboratory and unit laboratories.5 Each of the hospitals composing the center was to be served by a unit laboratory. The center laboratory was to perform such examinations as required greater time and more technical skill, while the unit laboratories were to perform ordinary routine clinical pathological examinations.5

In order to illustrate the laboratory activities at these centers there follows the history of that service at Mesves and at Vichy. The organization and activities of the laboratory service at Mesves, which grew to be the largest center in France, were typical of those in other centers,5 except Vichy. This service at Vichy is, therefore, described also because of its unique character.

TYPICAL LABORATORY ORGANIZATION OF A HOSPITAL CENTER (MESVES)

The first base hospital assigned to Mesves, arrived August 1, and on August 3, a laboratory officer for the center was assigned.6 Efforts were inaugurated and continued to provide accommodations, equipment and organization for the laboratories of base hospitals as they successively arrived. Construction was expedited, by loaning to these units a Medical Department tool chest, by which construction of much apparatus, shelving, furniture and other articles was expedited-apparently a minor matter, but one which proved of very


173

great importance. Supplies were procured on requisition from intermediate medical supply depot No. 3.6

In conformity with Memorandum No. 8, division of laboratories and infectious diseases, July 23, 1918, the laboratory organization for this center comprised (1) a central laboratory whose commanding officer was a member of the staff of the commanding officer of the center, and supervised all its laboratory activities; and (2) unit laboratories, viz, one for each of the hospitals composing the center and the convalescent camp. The work of these departments was divided as follows:6

Center laboratory: (a) Special pathology (gross and miscroscopic); (b) special bacteriology (pneumococcus type, typhoid, and dysentery); (c) Serology (agglutination and complement fixation reactions); (d) general board of health for center (water analysis, carrier work); (e) preparation of media, purchase and requisition of supplies).

Unit laboratories: (a) Gross pathology (autopsies on all patients dying in hospital); (b) bacteriology (general culture work, blood, throat, wound, etc.); (c) general clinical pathology (urine, sputum, blood, feces, etc.); (d) preparation of Dakin's solution, care of unit water supply, etc.

This partition of duties was inaugurated August 15, 1918, and continued unchanged, though in September it was apprehended that laboratory supplies available for incoming units might not be adequate for the performance of all the duties allotted them. Laboratory work, however, was simplified by the practice of distributing patients, according to their ailments, among the hospitals best equipped and otherwise qualified to care for them.6 The distribution of duties proved highly satisfactory, but a conviction grew that centralization of post-mortem service and burials might have been advantageous, although this would have deprived clinicians of opportunities to attend autopsies in which they were interested.6

The center laboratory, until September 17, occupied quarters in common with those of Base Hospital No. 67, when it moved to a special building provided for it. This was 100 by 20 feet in dimensions and was later supplemented by a cool room 6 feet by 6 feet 6 inches, and an animal house 13 by 26 feet. These buildings were occupied several weeks before they were equipped with light, water, or sewer connections.6

Each unit laboratory centrally located in the hospital which it served occupied a building 20 by 40 feet, divided originally into an autopsy room, a morgue, and a clinical laboratory, but several changes were made in the interior plan of these structures. Each laboratory built most of its interior fittings.6

All laboratory supplies reaching the center were invoiced to the center laboratory officer and by him issued on memorandum receipt to the unit laboratories. In connection with such supplies, many economies and improvisations proved necessary. The supplies most difficult to obtain were those commonly used articles not listed in Memorandum No. 21 from the division of laboratories and infectious diseases, e. g., stoves, books, basins, pens, wire, etc. Animals, except mice, were procured without difficulty.6

Records were kept in the following manner: Request slips were made out in the wards and on these slips laboratory findings were entered, the slips then


174

being returned to the wards. Retained laboratory records consisted of (1) a journal or daybook in which all specimens or requests were listed; (2) a file of index or ledger cards on which the reports mentioned above were transcribed. All the work done on a given case was entered on one or more of these cards. This system simplified clerical work and facilitated cooperation with the clinical services.6

General reports of infectious diseases were carried on spot maps and on separate card indices for the more important diseases-pneumonia, diphtheria, typhoid, dysentery, meningitis, and scarlet fever. These records were obtained from (1) the morning report of infectious diseases, (2) from individual reports of cases which were required by a special memorandum of the commanding officer of the center, and (3) from the medical consultant. Each case of diphtheria, meningitis, and typhoid fever was personally investigated by an officer from the center laboratory. Routine reports of water analyses were made to the center sanitary inspector and to each hospital. The locations of all Lyster bags were posted on spot maps, to facilitate checking the routine bacteriological examinations. 6

The laboratory staffs of the entire center consisted of 29 officers, 7 nurses or civilians, who had had previous laboratory experience, and 63 enlisted men. Of this number 5 officers, 1 technician, and 15 enlisted men served at the center laboratory, while the others were distributed among 8 base hospitals, 2 provisional base hospitals, 2 evacuation hospitals, and the convalescent camp.6

The idea of developing the laboratory service from a central laboratory with subsidiary laboratories in each hospital organization proved practical and efficient. As each hospital occupied somewhat the same position in the center that the regiment held in a division, this organization, more than any other factor, simplified the development and operation of the laboratory service. The old and established functions of the laboratory proved of most value, but the preparation of Dakin's solution and the supervision of the water supply in each hospital by its laboratory, in addition to the regular bacteriological examinations of the camp water supply, were other valuable services. Wound bacteriology and pneumococcus typing proved of little practical importance.

With the exception of influenza and influenza pneumonia, there were no epidemics in this center. Diphtheria was the most prevalent of the carrier-borne diseases (151 cases), and the number of diphtheria carriers detected was correspondingly high (112 cases). The presence of diphtheria and of virulent diphtheria-like organisms in wounds was frequently noted. Twenty-six cases of cerebrospinal meningitis were treated, of which 12 died. Twenty-five of these cases developed in this center. Seventy-three cases of typhoid fever, one case of paratyphoid A, and two cases of paratyphoid B were treated, of which total, 21 were believed to have originated here. Thirty-eight of these cases were verified bacteriologically.6

THE LABORATORY SERVICE , HOSPITAL CENTER, VICHY

The organization of the laboratory service at the hospital center at Vichy differed from that in other centers because of the fact that it appeared advisable to centralize all laboratory personnel and equipment. This decision arose


175

from the fact that the hospitals comprising the center operated in some 80 hotels which varied in their capacity from 50 to 1,200 beds. Because of the consequent unevenness in the distribution of buildings and bed capacity, operation of unit laboratories would have been difficult. In one hotel, accommodating 1,200 beds, one small subsidiary laboratory was established but this was the only departure from this plan for centralization. 5

The laboratory equipment of the five base hospitals at this center was, therefore, assembled at the center laboratory to which all Medical and Sanitary Corps officers belonging to the laboratory staffs of the various base hospitals were assigned. Enlisted men who had had previous experience as laboratory technicians, photographers, and artists from all organizations were similarly assigned.5

The laboratory and its enlisted personnel occupied an entire hotel with the exception of three small rooms which were assigned to the American Red Cross for office purposes.5

In this, as in other centers, an experienced laboratory officer who was assigned to the staff of the commanding officer of the center, organized and controlled its laboratory service, and was responsible for its activities.5

The laboratory staff here consisted of the following personnel: 5 Medical officers, 9; Sanitary Corps officers, 2; civilian employees, 4; enlisted men, 35; French employees, 7; total, 57. This personnel was distributed among the following departments: Administrative, pathological (including clinical and neuropathological), bacteriological, serological, art, photographic, and preparation of media.5

The administrative department had charge of the laboratory building, its proper policing, discipline of the enlisted personnel, the cleaning of glassware, operation of stock rooms, collection of specimens, and the issue of laboratory reports.5

The assistant director of the laboratory took complete charge of any large bacteriological problems that arose, such as extensive investigations for diphtheria, meningitis, or typhoid carriers, and was authorized to detail as his assistants any subordinate member of the laboratory staff.5

So far as possible the laboratory staff of each of the five base hospitals composing this center performed the routine laboratory work of their respective hospitals; e. g., clinical pathology, wound bacteriology, etc. Therefore, the service for each base hospital was left in charge of its own pathologist who was responsible to the laboratory officer of the center through the assistant director of the laboratory.5

The pathological department had entire control of the autopsy service and of surgical pathology. The laboratory officer of each unit performed practically all the autopsies pertaining to it, but the brains and spinal cords were removed by the neuropathologists and their technicians. All patients dying at this center were autopsied, a stenographer taking the dictated protocol at the post-mortem table. Almost every autopsy included an examination of the brain, spinal cord, and accessory sinuses of the head.5 This department was able to prepare microscopic sections of the important viscera from most


176

of the autopsies, to study them, prepare microphotographs and, with the aid of the art and photographic departments, to make drawings of gross and microscopic lesions. Clinical pathological meetings which the entire medical staff of the center were requested to attend were held three times a week in the lecture room of the laboratory. At these sessions clinical histories of all cases coming to autopsy were read and discussed, the gross anatomic material was demonstrated, and microscopic sections, drawings, charts, etc., were exhibited.5

FIG. 9.-Pathological room in the laboratory, Vichy hospital center

Wassermann tests, the typing of pneumococci, weekly water analyses and such other procedures as required more or less routine work, were assigned to a few officers and men and the individual base hospitals' laboratory staff was thus relieved of these duties.5

Though serology was done by the department of that name there was always opportunity for the laboratory staff of each base hospital to perform any of this work, if they so desired and had the time.5

The art and photographic departments had charge of all the medical art work of the center. Reenforced by a special group sent from the United States, this department was engaged in taking photographs of clinical cases, making black and white drawings, and colored drawings of gunshot wounds,


177

mustard gas burns and peripheral nerve injuries. It also took photographs or made drawings of surgical specimens, autopsy lesions and constructed plaster or wax models of facial injuries and other lesions. When the armistice was signed, this department was prepared to furnish on request, medical photographs and artists to other hospitals. It was planned and to a large degree accomplished that this center be made a collecting point for medical art work in the American Expeditionary Forces.5

The basement of the hotel utilized for laboratory purposes, contained the morgue for the entire center with a central autopsy room. Another room on this floor used for the preparation of bacteriological media was equipped with hot and cold water, gas and electricity. In a third room were stored the coffins which were made by the Quartermaster Department while a fourth room was shelved and used for the storage of antitoxins, sera, vaccines, etc.5 Offices of the laboratory officer and his assistant and a small medical library were on the ground floor. Another room accommodated a large clinical and bacteriological laboratory which provided a desk bench for the pathologists and laboratory personnel of all the hospitals in the center. Most of the routine work was done in these rooms. On the same floor were a lecture room seating about 100 persons (also used for a museum and for the display of the work of the art and photographic departments) and a media and chemical supply room which served the entire laboratory.5

On the first floor were located the pathological, art, and photographic departments. These afforded facilities for officers engaged in histology and the preparation of gross pathological specimens for museum purposes, for artists engaged in medical art work, for a modeler of plaster and wax preparations for face masks, etc. Here were provided storage of pathological specimens for shipment to the Army Medical Museum, a portrait studio, and facilities for developing and mounting photographs. The brains removed from all cadavers were hardened, studied, and stored for shipment to the Army Medical Museum.5

The second and third floors of the hotel were used for living rooms for the laboratory personnel, about 40 being quartered there. All the rooms in this building were well equipped with water (hot and cold), gas, and electricity.5

The laboratory equipment and apparatus were excellent. Much of the equipment was brought to France by the several base hospitals, but additional articles were obtained from the medical supply depot and the central Medical Department laboratory. The equipment compared very favorably with that seen in most large civil institutions. An elaborate equipment for neuropathological work, consisting of large brain microtomes, etc., costing about $18,000, was shipped to the center from the United States but was never received.5

The methods of procedure employed by the laboratory in the service of the scattered hospital establishments were comparable to those used by departments of health in a civil community supporting a diagnostic bacteriological laboratory.5

As glassware containers for the collection of specimens were quite limited, small stations supplying this material were established in the largest of the


178

hotels occupied by the several hospitals. These culture stations, as they were called, were usually located in the pharmacy of the building. At one time 22 of these stations were in operation, and at each the laboratory maintained an adequate supply of the containers for urine, feces, or sputum; diphtheria culture tubes, wound culture tubes, and "venereal outfits," the last mentioned consisting of glass slides and swabs for taking smears.5 From each station containers for the collection of specimens were distributed as required to smaller buildings and conversely here were collected specimens and requests for laboratory service.

Pasted on each container was a mimeographed blank for the entry thereon of appropriate data. Similar detached blanks were kept at the culture stations for use as requests upon the laboratory for special services.

FIG. 10.-Bacteriological laboratory, Vichy hospital center

In an emergency, e. g., a blood transfusion, or a leucocyte count in an appendicitis case, there quest was sent direct to the laboratory by an orderly, and delivered to the pathologist of the hospital in which the soldier was a patient. This officer was responsible for an immediate laboratory examination. None of the Army forms or blanks were employed in the laboratory service here.5

Three enlisted men, who acted as culture collectors, visited each of the culture stations three times daily, employing a motor cycle and side car.5

All specimens brought to the laboratory by the culture collectors or sent direct by a hospital were noted in numerical sequence on an entry book at the


179

receiving office. The specimens were then distributed for examination and the results of these examinations were noted upon report blanks, the laboratory retaining a carbon copy for its file, the original copy being sent to the hospital and ward from which the specimen came or for which the examination was made.5

Though the laboratory at Vichy existed for a year, it operated actively only for five months. During this time, 44,767 laboratory examinations were made, including practically all the common tests, reactions, and procedures required by modern clinical medicine in bacteriology, serology, clinical pathology and pathological anatomy.5

BASE HOSPITAL LABORATORIES FOR BASE HOSPITALS NOT OPERATING IN CENTERS

The laboratories of detached base hospitals performed all routine clinical and pathological work for the organization they served. Their installation was a matter of local administration and their operation presented no difficulties.7

Many of the following details, taken from the history of the laboratory activities of Base Hospital No. 27, are illustrative of the activities of those establishments in detached base hospitals generally. This unit was selected for discussion here because of the completeness of its history.7

The staff of the laboratory originally consisted of 3 medical officers, 1 trained nurse, and 3 enlisted men. One officer was engaged in pathology, another in bacteriology, and the third (who gave part of his time to ward work) in clinical microscopy, parasitology, and chemistry. Late in November, 1918, a Sanitary Corps officer joined the staff, but at intervals one or more officers were detached for periods of three months or less. The services of civilian photographer and artist were made available to this unit and thus some valuable material in this field of endeavor was procured.7

The laboratory of Base Hospital No. 27, which was located at Angers, first occupied two rooms in a permanent building. Since these rooms were overcrowded, a temporary structure was obtained into which the laboratory moved as soon as the new building was completed. This building was centrally located and was of the wooden barrack type, with cement floor and plaster walls. The floor plan included two workrooms, measuring 6 by 12 meters, with an incubator room 2.5 by 2 meters and a storeroom 2 by 2 meters between them, one on either side of a short passage connecting the two large rooms.7 The workrooms contained benches, along both sides, and center tables. Large sinks, supplied with hot water and adapted to cleaning glassware, etc., were provided for each room, and a sufficient number of small sinks for the side or center tables. Both rooms were wired for electricity, with numerous ceiling and side lights and a number of floor plugs at the sides of the room. Ample shelf space was provided, the storeroom being shelved to the ceiling. Gas connections were installed along all the side tables. A hot-air sterilizer, a paraffin oven, and a large centrifuge were operated in the incubator room, and the Arnold sterilizer and the autoclave in the bacteriological room. As far as possible, the reserve supply of laboratory materials was kept in the storeroom.7


180

When the temporary structure was occupied, the rooms whence the laboratory moved were thoroughly equipped as a morgue and as a fixation room for specimens.7

The equipment originally brought to France was that estimated on the basis of the needs of a 500-bed hospital for one year, but when the bed capacity was doubled (or counting emergency beds, quadrupled), a requisition was submitted for corresponding additions to equipment. Availability of gas and electricity secured the issue of apparatus not considered in the original list of equipment.7

Arrangements for the delivery of specimens to the laboratory were left to the respective ward surgeons, but phenolphthalein tests, diagnostic lumbar punctures, procurement of specimens for Wassermann tests, blood cultures, and blood counts were all attended to on request to the laboratory staff.7 Each specimen was accompanied by a requisition slip upon which the reports desired were entered and was returned to the proper ward by the laboratory personnel. Laboratory records were kept for the most part in separate ledgers, one for each class of work, e. g., blood counts, urine analysis, etc., but general bacteriological findings were recorded in one book and wound bacteriology findings in another, each in numerical sequence. Record of examinations of surgical pathological tissues were entered on the original requests for examination. These were retained at the laboratory and duplicates of the findings noted were sent to the wards. Autopsy records were made on appropriate forms with histological notes appended when necessary to make the diagnosis complete. Wassermann tests were recorded on cards, each day's list being entered on a separate card.7

The chief activities of the laboratory were clinical pathology, anatomic pathology and clinical bacteriology. A considerable part of the bacteriological work was incidental to the epidemiological study of cultures from this and other hospitals in the vicinity of Angers.7 The laboratory also made the water analysis for this region.

The somewhat limited official personnel and lack of trained technicians necessitated such close cooperation and application to the routine work in hand that research work was precluded.7

CAMP HOSPITAL LABORATORIES

Effort was made to furnish each camp hospital with laboratory service in accordance with its requirements.4 This was not entirely uniform, for these hospitals varied greatly in size and in the nature of their service. Some functioned as base hospitals; others were little more than evacuating infirmaries, or varied between these two extremes. In November, 1918, 58 camp hospitals were operating with the American Expeditionary Forces and there is record of  laboratory service in 51 of these.

The following notes from the history of the laboratory of Camp Hospital No. 15, exemplified to a degree the activities of these units.8 This hospital was organized in France from casual personnel. Its capacity was 700 beds, expansible to 1,000 beds in emergency. Located at Camp Coetquidan, which accommodated 20,000 troops, the hospital began to admit patients November 1,  l9l7.8


181

The laboratory staff consisted of one officer and four enlisted men. At first equipment was very limited but was augmented from time to time as resources permitted by American and French apparatus. The laboratory occupied two rooms, with floor areas of 50 and 25 square meters respectively, in a centrally located permanent building and utilized rooms in a neighboring structure as a morgue and an animal house.8

Requests for examinations as well as specimens were sent to the laboratory by ward surgeons. Findings were recorded in note books and reports then rendered the ward officers. Requests from officers outside the hospital were sent through the receiving ward, and reports returned through the same channel.8

An important part of the laboratory service was the periodic examination of water supplies in villages where troops were located throughout the surrounding territory, and sanitary surveys, with studies pertaining to epidemiology among the troops occupying the area. As meningococci were discovered in the course of the influenza epidemic at Camp Coetquidan, approximately 8,000 cultures for these organisms were examined, of which 662 were positive. Because of limited equipment, chemical examinations were few.8

MOBILE LABORATORIES

ARMY LABORATORIES

In the original plan of organization, a laboratory unit for each army was provided, but it was thought best to await developments before the project was further defined.1 Until July, 1918, all laboratory investigations of outbreaks of epidemic diseases in the advance section and zone of the armies were performed by personnel and motorized laboratories-i. e., "field laboratory cars"-sent out by the central Medical Department laboratory or Army laboratory No. 1.1 During the Chateau-Thierry operation, a field laboratory car was attached to the First Corps for the investigation of epidemic diseases and it was understood by the chief surgeon of the Paris group, of which that corps then formed a part, that this car was available for the service of the entire group. The work of this unit in the Chateau Thierry sector proved to be of great value, for it demonstrated that much of the so-called diarrhea and dysentery occurring there was true bacillary dysentery, typhoid or paratyphoid.1

In August, 1918, it became evident that there should be attached to each army a laboratory unit equipped to do general bacteriology, serology and examination of water supplies.1 A transportable laboratory equipment for service of the first army was assembled and shipped to Toul just prior to the St. Mihiel operation (September 12, 1918). As special personnel was not immediately available, the equipment was installed at the Toul hospital center where the laboratory served the center and also met the emergency requirements of the First Army.1

During the early phases of the Meuse-Argonne operation, a field laboratory car was attached to the First Corps of the First Army.1


182

When the Second Army was formed, a field laboratory car was attached to the office of the surgeon of that army. It operated under the sanitary inspector, Second Army, in the investigation of epidemic diseases.

When the Third Army was organized to constitute the Army of Occupation in Germany, a survey of the laboratory requirements was made and the personnel and equipment necessary for its service were supplied.9 Army laboratories were established at Coblenz and at Trier, that at Coblenz being supplemented by a mobile laboratory.9

The laboratory service of the Third Army illustrates the full development of this specialty in this field. On March 16, 1919, it included 2 army laboratories, 10 hospital laboratories with 2 annexes, and 8 divisional laboratories; i. e., 1 for each division.9

The army laboratories were staffed and equipped to perform all the ordinary duties of laboratories serving large cities or even States. The personnel of the unit located at Coblenz consisted of 10 officers and 24 enlisted men, excluding those assigned to the field laboratory car which also served this army and which was attached to this unit.9 It included a commanding officer, executive and supply officers (one officer sometimes discharging the duties of both assignments) a pathologist and histologist, bacteriologist, water analyst, serologist, chemist (with exceptionally broad attainments, especially in the field of toxicology), three clinical laboratory experts, and a skilled technician.9At the army laboratories autopsies were performed, histologic diagnoses and Wassermann tests made, bacteriologic differentiations conducted, water samples tested and chemical analyses made of food, beverages, medicines and supplies, e. g., chlorinating materials for water purification.9 Each of these units also conducted a clinical laboratory service for the hospital wherein it was located and issued supplies to other laboratories in their respective areas. The laboratory at Coblenz performed the usual laboratory service for Evacuation Hospital No. 27 (formerly No. 6) and sent out officers to conduct autopsies at other hospitals. 9

Attached to the Third Army laboratory at Coblenz was a field laboratory car which was staffed by one officer and three enlisted men. This unit was of especial value during the initial emergency and in the prosecution of surveys of meningococcus
carriers.9

The army laboratory at Trier occupied space in Evacuation Hospital No. 12, for which it performed all the clinical laboratory service in addition to its other duties, which were similar to those outlined above for the laboratory at Coblenz.9

Ten laboratories each adequately equipped with material packed in eight chests, served the 10 evacuation hospitals, which in the Third Army served as base hospitals.9 These hospitals varied in capacity from 400 to 1,800 beds and in the character of the cases treated. In some units the cases were almost entirely medical, in others many cases were surgical; a few units were largely devoted to the specialties. The laboratory service in each of these hospitals naturally conformed to the character of the patients treated therein. In very general terms this service included examination of urine, sputum, blood, cerebrospinal fluid, feces, and the bacteriology of wounds, epidemics, venereal, cutaneous, and ocular diseases, i. e., the usual lines of investigation connected with hospitals.


183

The staffs of some laboratories also performed autopsies for the hospitals which were not thus served by the army laboratories.9

No laboratories, other than the eight assigned to divisions, were provided for the field hospitals, of which 35 were in operation. These divisional laboratories, each provided with 8-chest equipment, were utilized to make water analyses, epidemiological studies and urgent clinical laboratory examinations.9

FIELD LABORATORY CARS

Each of the field laboratory cars, which on occasion reenforced the laboratory service of armies, was essentially a completely equipped unit, relying on its own motor power, but was supplemented by additional transportation consisting of a Ford car and a motor cycle with side car.10 The unit could be shifted and moved rapidly to meet varying conditions in the field as well as to cover a large territory and was independent of field, evacuation, and base hospitals. The additional transportation permitted sanitary surveys covering a large area and facilitated the collection of specimens for examinations.10 Three of the cars were the Peerless type and one a De Dion Bouton. They were specially designed and equipped to meet field conditions, for oftentimes the laboratory would work in a division removed from hospitals and other laboratories.10

FIG. 11.-Field laboratory car

The equipment was compact and provided with a work bench and compartments for the apparatus and supplies. The arrangement made work in the car possible and prevented breakage while the car was being moved. The provisions made for actually doing work in the car constituted one of its greatest


184

advantages, but usually a room in some building was utilized for making media, washing glassware, and for a storeroom. Occasionally one was fortunate enough to be located where the apparatus could be set up in a separate room.10

The equipment consisted of incubators, autoclave, hot air sterilizer, distilling apparatus, ice chest, water bath, Wassermann outfit, centrifuge, microscope, hemocytometer, water testing outfit, material for spinal punctures, blood cultures and the usual laboratory accessories. A storage battery and generator, connected with the motor, provided electric lights. This was of great help, for often it was necessary that work be done in the car at night. This apparatus also gave excellent illumination for microscopical examinations.10 A gravity water system was provided, consisting of a water tank fastened on the roof of the car and connected with a faucet. A sink drain was also provided. Supplies were carried in the car to make the necessary media, a complete supply of diagnostic as well as therapeutic sera, and reagents for the Wassermann test. The equipment made possible the performance of the following laboratory tests:10 Routine clinical examinations, such as those of urine, blood, sputum, smears and body fluids; examinations for typhoid, dysentery, and enteric ailments generally; examination to determine positive diagnosis of meningitis and examination for carriers; examinations for diphtheria cases and carriers, and performance of Schick tests; investigation of respiratory epidemics, especially pneumonia and influenza; water analyses, bacteriological; Wassermann fixation test. These laboratories were not called upon however, for this work.

FIG.12.-Front of interior of field laboratory car


185

FIG. 13.-Rear of interior of field laboratory car


186

FIG. 14.-Interior of field laboratory car showing water still, autoclave, and sterilizers


187

The field laboratory car aided the sanitary inspector of an army to cope with epidemiological problems and it was in this capacity that it was of greatest use, though it was often called upon to assist in establishing clinical diagnoses.10 Being attached to army headquarters under the immediate supervision of the sanitary inspector, reports of its findings were made to him direct. The peculiar value of the laboratory cars rose from the fact that the divisional laboratories usually were unable to handle the larger epidemics and sanitary surveys, while performing their normal duties. The stationary laboratories were not provided with transportation for extensive field work though the collection of samples was of the greatest importance, while the excellent transportation facilities of the laboratory cars enabled them to reach sites where their services were needed and to carry supplies adequate for several months. These supplies usually were replenished from evacuation and base hospitals.10

The personnel consisted of 1 or 2 officers, 2 technicians (preferably sergeants or sergeants, first class), and 2 chauffeurs.10

These laboratories aided greatly in the investigation and control of typhoid fever in the 77th and 79th Divisions; meningitis in the 7th and 90th Divisions; diphtheria in the 32d and 35th Divisions; pneumonia and influenza in the 26th Division and in the labor battalion at Jonchery.10

The most important advantages which these laboratory cars presented were the following:10 The unit could function anywhere in the field, requiring no special housing or additional equipment and could, therefore, operate in any area occupied by the troops. It was supplied with its own light and water systems. Being supplied with its own motor power it was ready for immediate service and the transportation could not be diverted for other use, thus ensuring a mobile organization. The unit was able to handle large epidemics and to cooperate with the army sanitary officer in solving special problems and making surveys. It thus permitted other laboratories and those with divisions to continue their normal duties without interruption. On the other hand, the chief disadvantages of a field laboratory car were, the initial cost of the car and its special equipment, which was about $7,500; the car being of special design, could be manufactured only in limited numbers, and in case of motor trouble the whole organization was unable to function.10

EVACUATION AND MOBILE HOSPITAL LABORATORIES

The laboratory equipment for each evacuation and mobile hospital was assembled in eight chests which could be packed and unpacked quickly and could be easily transported.4 It was adequate for all types of clinical and general bacteriological work, for the performance of autopsies, and the collection and preservation of museum specimens. As a rule, only one laboratory officer and two technicians were assigned to the laboratory units which served hospitals under consideration though a larger personnel originally had been contemplated.4 The personnel prior to assignment was given a special course of instruction in wound bacteriology. It was planned that these units would perform clinical pathology and autopsies as well as general and wound bacteriology and collect and preserve museum specimens, and work of this general character was per-


188

formed at those evacuation and mobile hospitals which were partially immobilized and operating in quiet sectors, but after July, 1918, when a war of movement began, the activities of many of these units necessarily changed.4

During 1918, the number of evacuation hospitals, each of which was equipped with a laboratory, increased as follows, until the time of the armistice: March, 1; April, 2; May, 2; June, 4; July, 8; August, 8; September, 13; October, 18; November, 18.11

The first evacuation hospital (No. 1) was established near Toul in March, 1918, where it operated throughout the remainder of the war.11 Except during periods of active military operations its services were to a degree comparable to those of a base hospital, but during active engagements they were of the character which its name indicated. As at all times it was almost exclusively a surgical hospital, its chief laboratory activities were wound bacteriology and post-mortem pathology. Similarly, Evacuation Hospital No. 2, established in April, at Baccarat, was engaged chiefly in the treatment of battle casualties and its laboratory during that period was occupied in corresponding service.11

FIG. 15.-Transportable laboratory, in eight chests

Wound bacteriology occupied intensively the laboratories of evacuation hospitals during the period from July, 1918, to the armistice; but during periods of greatest battle activity, laboratory officers often were detailed to assist in the treatment of patients.11 After the onset of the influenza epidemic in October, 1918, the laboratories were engaged also in the study of infectious diseases and frequently made the diagnoses for the ward surgeons. Post-


189

mortem examinations which they conducted on all bodies acted as a check against gross errors and furnished clinicians with invaluable information. Autopsies and histological and bacteriological examinations of specimens were made the occasion of clinico-pathological conferences.

During the Meuse-Argonne operation some of the evacuation hospitals were specialized to a degree, a number of them receiving medical cases and a number of others surgical.11 Their laboratories supplied information required for diagnosis and treatment and for the prevention of the wider spread of infectious diseases. In general terms the equipment of these laboratories was very satisfactory.11

FIG. 16.-Chests of transportable laboratory opened to show contents

When American troops took over their sector in occupied Germany this was divided into two districts, that of Coblenz and that of Trier. Seven evacuation hospitals served the six divisions in the Coblenz or Bridgehead district, and two, the two divisions in the district of Trier. Since these units operated as advanced base hospitals and some of them specialized on certain types of cases, the activities of their respective laboratories were modified accordingly. The laboratories in each district were supplemented by an army laboratory which conducted the more highly technical examinations in bacteriology, chemistry, pathology and serology.11 The personnel of the army laboratories also performed the duties of consultants in special problems, especially surgical pathology, conducted depots of laboratory supplies and apparatus and performed autopsies for the hospitals in their vicinity.


190

FIG. 17


191

With a few isolated exceptions the work of the laboratories in the evacuation hospitals would have compared favorably with that in the average civilian general hospital, for in spite of the deterrent influences of campaign they proved their utility-in fact their indispensability.11 The laboratories proved to be of immediate clinical value in both medicine and surgery and collected a number of specimens for the Army Medical Museum.11

The laboratories of mobile hospitals were especially engaged in wound bacteriology, for these units were organized to receive the nontransportable wounded.12 They made, however, a number of examinations in other fields, as blood and throat cultures, differential blood counts, examinations of joint, spinal, and chest fluids, of blood, sputum, urine, urethral smears, and feces.13 Serum for Wassermann tests was collected and sent to designated laboratories. Autopsies were performed and museum specimens collected.13

FIG. 18

Some of these laboratories moved quite frequently, that with Mobile Hospital No. 1, for example, changed station nine times in five months.12 Some used tentage but when possible a room in a permanent or temporary building was employed. The equipment issued was found to be ample. Many technical expedients were employed in the effort to expedite reports to the attending surgeon.12

DIVISIONAL LABORATORIES

A laboratory attached to each division was staffed by two officers and four technicians,4 who constituted a part of the staff of the division surgeon.


192

In close cooperation with the division sanitary inspector, these units were engaged chiefly in control of epidemic diseases, in the inspection of water supplies, and supervision and control of water purification.4 In effect they were under the control of the sanitary inspector. The equipment issued these units was packed in three chests and was not adequate for general bacteriology, for it was planned that work pertaining to that specialty would be performed in the laboratories of evacuation and mobile hospitals.4 Such material as was furnished for work of that character was adequate only for the performance of routine clinical examinations.4

After the armistice began, when divisions went into training areas, many of these laboratories requisitioned and procured additional chests to complete equipment adequate for general laboratory work, including general bacteriology.1 All the divisional laboratory units with the Third Army were supplied with complete transportable laboratory equipments, in eight chests each, thus permitting general bacteriological and clinico-pathological work.1

FIG. 19

On July 7, 1918, in Memorandum No. 5, division of laboratories and infectious diseases, the personnel, transportation, and duties of the divisional laboratory unit were prescribed in some detail.1 The provisions of this circular were later republished and somewhat amplified, in Memoranda Nos. 5 and 7 from the same office 1 (see Appendix).

These units usually were located at division headquarters, especially when the division was in a rest or training area or at headquarters of the sanitary train. In trench warfare or in training or rest areas the divisional laboratories


193

usually occupied two rooms in some building, preferably where heat, light, and water were available. During battle, as a rule, they were from five to seven miles behind the front, often in open fields, by the roadside, in tents, dugouts or unused buildings.14 Under combat conditions it was found expedient to divide the laboratory, the bacteriologist and sufficient personnel being located with the bulk of the laboratory equipment at one of the field hospitals, preferably the surgical hospital or one used for evacuation purposes.14 This part of the laboratory supervised the preparation of Dakin's solution and dichloramin-T and performed general bacteriological and pathological services. The other part, with the water supply officer and two enlisted men with the necessary equipment, tested for poisons the water supplies in advanced positions, selected water points, and examined treated water for free chlorine.14 Facts learned by this party were promptly reported to the water-supply engineers, who then supplied the personnel and equipment necessary to produce a satisfactory drinking water. The water supply officer was charged with purification of this water if necessary and with successive checks upon it. Chemical analyses that required the use of standard solutions presented difficulties that could hardly be overcome in the field, but it was found expedient to test all water sources for poison during advances. This was readily feasible.14

FIG. 20.-Showing preparations for shipping portable laboratories from the central Medical Department laboratory, Dijon

Also in training or rest areas the laboratory cooperated in the location of water sources, determined the quality of their outflow, and performed the chemical and bacteriological tests incident to the control of water service.14


194

No hard and fast rule could be laid down for methods of procedure in rest areas, trench or open warfare. Methods in one field were not applicable in another, but when the division was engaged in trench warfare they were similar to those followed when in a rest or training area. Under the latter circumstances as much work as possible was placed on a routine basis.14

Whether at the front or in training or rest area the value of these units was clearly demonstrated, for they very materially strengthened the service of the sanitary inspector. A case of suspected epidemic disease arising in a regiment was immediately reported to the division surgeon and was sent to a field hospital where cultures were taken and forwarded by courier to the laboratory.14 If a diphtheria culture was found positive, contacts also were examined within two hours. The usual routine work arising in field hospitals was handled very readily by a courier service.14

The success of laboratory activities was commensurate with the ability of the unit to maintain close contact with the division surgeon and sanitary inspector, to adapt itself to field conditions, and to make the most of the limited facilities at hand.14

While some of these units did admirable work and were considered indispensable by some division surgeons, a large percentage were unable to function properly under combat conditions. The principal reason for this failure was lack of transportation. These laboratories had been included in the tentative tables of organization formulated for the American Expeditionary Forces, and adopted in August, 1917, but no transportation had been provided for them at that time.1 For some reason, unknown to the division of laboratories, they were incorporated in the priority shipment schedule as "mobile laboratories" and as Services of Supply units.1 Several efforts were made to secure transportation for these formations, and the inclusion of the personnel and their transportation as divisional units was recommended by the director of laboratories in the proposed revision of the Tables of Organization, when these were under consideration during the summer of 1918. This proposed revision had not been approved on the date of the declaration of the armistice.1 Had even a motor cycle been available for each of these laboratories there is but little doubt that water discipline would have been better throughout the division, with a consequent decrease in the prevalence of typhoid and paratyphoid fevers and dysentery.1 Lack of transportation in a number of cases caused the elimination of these laboratories as divisional units.14

In January, 1919, on special request of the division of laboratories, G-4, general headquarters, directed that one motor cycle with side car be issued to the divisional laboratory of each division still in France. This transportation permitted much closer and more satisfactory supervision of chlorination of water supplies in divisional areas.1

TECHNICAL WORK OF LABORATORIES

Many types of technical laboratory work (e. g., gastric analyses, tumor diagnoses, etc.) of peace time had little place in the laboratory service of the American Expeditionary Forces. Instead of these, large numbers of examinations of relatively few ordinary types prevailed, with occasionally a highly specialized study to meet an emergency.4


195

The officer in charge of a laboratory assisted the attending medical officer and the surgeon by making urinalyses, blood-cell examinations, etc., and by determining the types of bacteria in wounds.4 His work was final in the diagnosis of many infectious diseases, and for the specific prevention and treatment of these he cooperated in the administration of vaccines, therapeutic sera, salvarsan, etc. He was consultant to the epidemiologist concerning the essential cause of a prevailing disease, the identification of immune carriers, and the character and extent of water pollutions.4 He inspected in large part the chlorination work of the water-supply service and in some measure the professional work of attending medical officers by determining at autopsy any error in diagnosis or treatment.4

The technical work of the laboratory section of the division of laboratories was so modified by the stages of development in its organization, by the incidence of epidemics and by active military operations that its history, for present purposes, is divided roughly into four periods: (a) From the first landing of troops, June 10, 1917, to November 30, 1917. Toward the latter part of this period a large number of cases of pneumonia developed. (b) From December 1, 1917, to May 31, 1918. It was during this period that activities of the hospitals of the American Expeditionary Forces began to be actively concerned with battle casualties. (c) From June 1, 1918, to November 30, 1918, the period of serious epidemics and of greatest battle activity, during which time the laboratories generally were concerned largely with enteric disease, influenza, and wounds. (d) The period of demobilization after December 1, l9l8.15

The first period, that from June 10, 1917, to November 30, 1917, was one of tentative organization when the laboratories were engaged chiefly with the clinical pathology and bacteriology incident to ordinary illness and to accidents in a small body of troops in the services of supply or in training.15

On August 28, 1917, the director of laboratories submitted to the chief surgeon, A. E. F., certain suggestions concerning autopsies, the rendition of autopsy protocols, and the scope of the latter, and recommended that a bulletin concerning these matters be issued from the chief surgeon's office.16 The Wassermann service was begun in September, 1917.15 In the few laboratories then operating (4 camp hospital laboratories, 8 base hospital laboratories, and 2 section laboratories) a small but important autopsy service was begun.15 Very meager data concerning the technical laboratory work of this period are available, since no monthly reports were made.15

In the second period, from December 1, 1917, to May 31, 1918, additional laboratories in 12 camp hospitals, 3 evacuation hospitals, and 10 base hospitals, as well as the central Medical Department laboratory began to function, and the organization of the division of laboratories and infectious diseases was completed, thus greatly increasing the facilities for all types of technical work.15 Early in this period epidemics of pneumonia, diphtheria, scarlet fever, and meningitis among our troops taxed these facilities to their full capacity for routine clinical and bacteriological examinations.15 At the end of this period the system of monthly laboratory reports was begun, but the available information for most of the period was quite incomplete.15


196

When the German offensive of May 28, 1918, in the Marne area brought relatively great numbers of American wounded into our hospitals, the Medical Department was still very greatly undermanned in its laboratory as well as in its other services.15 So great was the need for medical attention that in many organizations all laboratory officers were diverted from laboratory work to the more direct care of the wounded. From this time until the signing of the armistice, laboratory officers were never available in half the number necessary to make the routine technical examinations, while research was, in general, wholly out of the question.15 However, laboratory officers succeeded in organizing and developing their laboratories, in doing most of the absolutely essential clinico-pathologic work, and in meeting emergencies, such as the performance of large numbers of bacteriological examinations and of autopsies incident either to battle casualties or to epidemics of enteric diseases, influenza, diphtheria, meningitis, etc.15 Until the 8-chest transportable laboratory units became available, the laboratory work was accomplished with equipment relatively so inadequate that the results obtained would have been considered practically impossible by laboratory personnel prior to the war.15 By November 1 the total number of laboratories in operation had greatly increased, as shown by Table 4, the personnel was advantageously distributed, and officers had learned to virtually "make bricks without straw." This third period of the laboratory activities of the American Expeditionary Forces-i. e., from June 1, 1918, to November 30, 1918-stands out preeminently as an index of how much may be done under most difficult conditions.15

The available information concerning the technical work for this period is fairly good. In May, 1918, a standard form (No. 5) for laboratory reports to the director of the division of laboratories had been devised and after June, 1918, this report was received monthly from most of the laboratories in operation in the American Expeditionary Forces. In October, 1918, this form was revised and improved.15 This monthly report, which was intended primarily to supplement the direct supervision from the office of the director of the division of laboratories, presented sufficient clinical information, concerning the activities of the hospital under "data for comparison," to enable the reviewer to determine something of the character and amount of work which should have been done by the laboratory and the personnel available for its accomplishment.15 Activities were divided into six groups among the personnel of the laboratory. All attempts to determine the clinical incidence, as of infectious diseases, were purposely omitted since it was believed that these more properly belonged to special reports of the section of infectious diseases and other agencies. The number of "positive" examinations in certain diseases was given merely to aid the reviewer in determining whether the clinician was underusing or overusing the laboratory.15 For example, a very high percentage of "positives" usually indicated underuse and a very low percentage suggested overuse. The careful review of each report immediately upon its receipt, and, if necessary, its return with a critical indorsement thereon, did much to improve the weak points in the service of some laboratories.15

The signing of the armistice marked the beginning of the fourth period of activity of the laboratory service. Many of its officers who had entered from


197

civil life requested orders for their return to the United States.15 These requests could not well be refused, though the quota of laboratory personnel was still far below that of any other branch of the medical service.15 The situation was aggravated by the fact that at this very time the appearance of typhoid fever in a number of organizations rendered necessary extensive bacteriologic examinations; thorough examinations for venereal disease were being conducted among troops in training areas, and potential danger points, which demanded increases of local laboratory service, were created by the concentration of troops in embarkation camps and at base ports.15 Because of decreased personnel and of the increased service demanded, much of the technical service of the laboratory division even in this final period was performed under stress. Fortunately, however, early in this period the receipt and distribution of laboratory supplies had been greatly expedited and this fact, coupled with the transfer of material from organizations being demobilized, greatly improved the physical conditions under which the service was rendered.15

As was inevitable, not all hospitals in the American Expeditionary Forces were staffed by attending medical or surgical officers well trained in the selection of cases in which clinico-pathologic examinations might be of assistance; nor were they all sufficiently trained in interpreting the results of these examinations. In some instances serious diagnostic errors were made which might have been prevented by even a urinalysis; in others the laboratory was called upon to make large numbers of difficult examinations in a search for the specific cause of a disease which was scarcely even suggested by the symptoms.15 Personal supervision by medical and surgical consultants did much to improve the clinical services in this respect but this was obviously inadequate to cover with sufficient detail the activities of several hundred hospitals. In hospital centers the assignment of the laboratory officer of the center to the headquarters staff greatly increased the efficiency of the laboratory service of the center and promoted its coordination with the other professional services.15

THE CLINICO-PATHOLOGIC SERVICE

The clinico-pathologic service up to November 30, 1917, constituted the bulk of the laboratory work, though it was far from large. During this period, there were few patients in hospital and, as the troops were mostly in the Services of Supply or in training areas, clinicians were able both to study their cases carefully and to utilize the laboratory facilities to good advantage.15 Many of the cases in hospital during this period were suffering from acute infectious diseases of respiratory types, though true pneumonias did not reach a high rate until December. A relatively high venereal rate which occurred in November, 1917, made necessary many routine laboratory examinations. The laboratory records for this period, however, are very meager, since regular monthly reports were not then made.15

The clinico-pathologic work for the second period, from December 1, 1917, to May 31, 1918, was similar to that of the first. The epidemic of pneumonia, beginning in the fall of 1917, gradually subsided, but a relatively large number of patients with other diseases, particularly meningitis, scarlet fever, diphtheria, and measles, were in hospital, and on these patients a large amount of clinico-


198

pathologic work of a routine character was necessary.15 The relatively high venereal rate in December, 1917, dropped materially toward the end of this period.15

The total amount of clinico-pathologic work done during the first and second periods was low in relation to the number of cases in hospital and to the number of both commissioned and enlisted personnel.15 This was due to difficulties in providing accommodations for laboratories, to lack of equipment, to untrained enlisted personnel, and in some instances to "overtrained" commissioned personnel. Many of the base hospitals in the American Expeditionary Forces which first arrived in France were manned on the laboratory side, as well as in the other professional departments by highly trained specialists.15 A number of these had been concerned in their recent civil experience only with teaching or research and a considerable period elapsed before some of them could readjust their ideals so as to properly evaluate simple routine clinico-pathologic examinations, such as those of urine and blood.15

For the third period-i. e., from June 1, 1918, to November 30, 1918-the records were fairly complete, though during this period the laboratory service being to the extent of only about 40 per cent of its normal strength, was so greatly overworked that preparation of detailed reports was very difficult.15

During the fourth period following December 1, 1918, a marked decrease in trained laboratory personnel developed though the continuance of influenza, the outbreak of numerous small epidemics of typhoid fever, and the more careful venereal survey of all troops, necessitated a large amount of laboratory work.15

It is not the purpose to give here numerical summaries of laboratory work, however, certain points of interest relative thereto should be mentioned.

Leucocyte counts showed a gradual monthly increase which was not commensurate with the greatly increased number of patients in hospital, and did not reach even an approximately proper proportion till February, 1919. This was most noticeable in the relatively small number of differential counts made and was probably due to failure of clinical officers to appreciate the importance of this diagnostic procedure or their failure to insist upon the necessity for such counts.15

Malaria examinations, which reached their highest number in August, 1918, were notable for their rarity though they probably covered the necessary field more completely than any other laboratory procedure. 15

Examinations of feces for parasites and ova and for entameba were altogether too few. There was little time for these during periods of great stress but during the fourth period they might have been more numerous. It is unfortunately true, however, that laboratory personnel properly trained in the technique of these examinations was seriously lacking.15 There was a sudden increase in the number of examinations for intestinal parasites in August, 1918, which continued until November of that year.15

Urine examinations were fairly numerous, but their distribution and quality were very irregular. In many hospitals the specimens were intelligently selected, properly collected, and carefully examined. In some, this was not the case. In others very few such examinations were made.15


199

In examinations of sputum for tubercle bacilli, as well as in those of urine, relaxation in thoroughness was prone to occur. Specimens which the laboratory officer knew were not intelligently selected or collected were apt to be superficially examined, thus rendering negative reports of little value.15 In some hospitals as many as four or five hundred specimens were examined with only four or five "positives" reported. It is true that these were intended as controls in cases of recovery from influenza and pneumonia, but it was suspected that in many instances the lack of care in the collection of sputum and the hasty search for bacilli made the negative findings of relatively little value.15 The number of examinations of sputum for tubercle bacilli gradually increased reaching their highest point in January, 1919.15

The number of examinations for gastric contents was relatively small in comparison with such as would have been necessary for an equal number of patients in civil hospitals. Most of the military patients being young, robust, and subject only to wounds and acute diseases, there was little necessity for the examination of gastric contents with a view of reaching a diagnosis of gastric ulcer or cancer.15

In addition to the chemical laboratory tests which were made in most suspected cases of this character, great reliance was placed upon roentgenology.15

The occurrence of sporadic cases of true epidemic meningitis at widely separated points in the American Expeditionary Forces, kept the whole Medical Department on the alert. While it can not be demonstrated beyond peradventure that had no measures been taken, serious epidemics of meningitis would have developed, yet it is probable that the early accurate diagnosis and the vigorous methods instituted in most instances immediately on the development of a single case, served in large measure to prevent epidemics.15 In this service the laboratory officer rendered inestimable assistance to the attending medical officer.15

Smears for gonococci showed a gradual monthly increase though not reaching a considerable proportion until February, 1919.15

Dark field examinations for Treponema pallida were considerably though not sufficiently increased after the armistice began.15 It was difficult to find enough officers to make the large number of necessary dark field examinations in a competent manner.15

Except in the few instances noted above, the general quality of the clinicopathologic examinations was good. A large number of clinicians had been trained in civil practice to expect and more or less intelligently to interpret these examinations. This counteracted the tendency on the part of some laboratory officers to relegate this work to untrained personnel.15

Up to November 30, 1917, very few post-mortems were made in the American Expeditionary Forces. The clinical service before that date was very light, the attending medical officers and surgeons had time to study their cases with great care, and thus the necessity for a post-mortem examination of the few cases that died was not very apparent.15 Of the post-mortems that were made, the records either were incomplete or in some instances lost, so that but 14 protocols for this period-representing about one-fourth of the deaths-were received in the offices of the director of the division of  lab-


200

oratories. Most of these autopsies were made at Army laboratory No. 1, Naval Base Hospital No. 1, and Camp Hospital No. 33.15

During the period from December 1, 1917, to May 31, 1918, the number of autopsies increased in May to 57 per cent of the total number of deaths in hospital. This was due in part to the fact that on April 2 Circular No. 17, (q. v. in the Appendix) was issued from the chief surgeon's office.15

By the end of May, 1918, there were in the American Expeditionary Forces laboratories serving 25 base hospitals, 8 evacuation hospitals, 32 camp hospitals, 4 Red Cross hospitals, and 1 mobile hospital, besides Army laboratory No. 1, the central Medical Department laboratory, and the base laboratory of the intermediate section, or a total of 70 hospitals and 72 laboratories, in addition to those pertaining to divisions.15

Less than 15 pathologists in the American Expeditionary Forces were then capable of making post mortems and intelligently interpreting the results. This condition was due in part to the long neglect of the autopsy service in many civil institutions in the United States with inevitable reduction in the number of pathologists, and in part to the overshadowing status of bacteriology in military laboratories.15 The autopsy service had not been established as a routine procedure in the Army but on the contrary, autopsies were made only on the written authority of the commanding officer of a hospital. However, in the American Expeditionary Forces the need of a routine autopsy service amounting in fact to a professional inspection of the diagnostic and therapeutic measures of officers engaged in clinical service, rapidly became apparent during the summer of 1918. Surgeons were called upon with little time for study or reflection to diagnose and treat enormous numbers of gunshot wounds with which they had had little or no previous experience. Even those who were well grounded in the general principles of surgery were forced to make decisions and institute treatment thereon without sufficient opportunity for study.15 As a result, there were many errors in diagnosis and corresponding errors in treatment.15 The worst of these could be determined only by the pathologist. Likewise, medical officers attending cases of gas poisoning, influenza, and pneumonia were confronted by conditions with which they were totally unfamiliar, and frequently were forced to make diagnoses and to institute treatment with a very meager knowledge of the facts. Here autopsies proved of tremendous importance for they afforded knowledge of pathologic lesions which the physicians treating the case could use in their subsequent diagnoses and treatment.15 When, in the fall of 1918, and in the following winter, numerous isolated epidemics of typhoid fever began to appear, the symptoms and physical signs, in any instances, were so obscure that the clinicians failed to make proper diagnoses and the pathologist was the first to recognize the true nature of the disease on the autopsy table.15

The director of the division of laboratories, in June, 1918, requested that 10 competent pathologists be cabled for from the United States, in addition to those coming over with hospital organizations.15 These 10 pathologists arrived in due time and assisted materially in improving this service. The activities in forward areas were now covered to better advantage by dividing the territory into sectors and placing at Baccarat, Toul, Souilly, and Paris,


201

respectively, competent pathologists attached to an evacuation or base hospital, with orders to act as consultants in their specialty for the surrounding areas.15 In addition to these measures, the importance of autopsies was brought to the attention of laboratory officers and commanding officers of hospital organizations by inspectors from the division of laboratories, by letters, and by indorsements on monthly reports.15 As a result, the autopsy service rapidly improved, though there were never sufficient competent pathologists in the American Expeditionary Forces to cover the needs at all points. There were not more than 50 or 60 pathologists among the 685 medical officers in the laboratory service when the armistice was signed, but the service had so increased during the summer and early fall of 1918, that autopsies were performed on 95 per cent of all deaths in hospital. In October the total number of autopsies reached 3,896.15 This was but 85 per cent of the deaths then occurring in hospitals for the autopsy service like every other was overwhelmed by the enormous number of deaths from influenza and by the battle casualties of the Meuse-Argonne operation.

The greatest number of deaths occurred in the base hospitals. After July, 1918, many more autopsies were done in camp hospitals than in evacuation and mobile hospitals for they not only were more numerous but many of them actually functioned as base hospitals.15 An attempt was made to study battle casualties, particularly gas poisoning, by centrally located laboratory officers who could be concentrated by the use of motor transportation at any point where casualties occurred. This plan, which was then employed in the French service, usually failed because of lack of transportation.15

Early in July the recording and cross indexing of autopsy protocols was begun in the office of the director of division of laboratories, but inadequate assistance rendered progress in this direction very slow.15

After the signing of the armistice, the release from duty elsewhere of a few competent pathologists made it possible to place the analysis of the autopsy protocols concerning a few diseases, on a better basis. In order to facilitate this work in the central laboratory and to obtain the benefit of the review by the competent pathologists scattered throughout the American Expeditionary Forces, three office letters concerning, respectively, influenza and pneumonia, gunshot injuries, and war-gas poisoning were sent out to laboratory officers selected because of their ability and experience.15 These office letters gave forms for the analysis by the laboratory officer of all cases coming to autopsy under his individual observation. On the receipt of these analyses in the office of the director of laboratories they were compiled and coordinated with one another and with scattered protocols from other laboratories. Two other compilations were undertaken, one on typhoid fever and another on tuberculosis. In addition to these, however, the other autopsy protocols contained a wealth of data for further study on a number of subjects; e. g., meningitis, dysenteries, and cardiovascular lesions. 15

One field of post-mortem examinations which might have yielded invaluable results from the purely military standpoint was entered by but one pathologist in the American Expeditionary Forces. This was the examinations of the bodies of soldiers killed in battle.15 This service did not necessitate the making


202

of autopsies, but was limited to a study of the site and character of immediately fatal injuries by a medical officer who had a good knowledge of anatomy and some appreciation of the character and effects of missiles.15

REFERENCES

(1) Report from Col. J. F. Siler, M. C., director of laboratories and infectious diseases, A. E. F., to chief surgeon, A. E. F. (undated), on the activities of division of laboratories and infectious diseases, from August, 1917, to July, 1919. On file, Historical Division, S. G. O.

(2) Report on the Medical Department activities of base section No. 5, A. E. F., undated, made by the surgeon, base section No. 5. On file, Historical Division, S. G. O.

(3) Report on the Medical Department activities of Camp Hospital No. 33, by First Lieut. George R. Cowgill, S. C. On file, Historical Division, S. G. O.

(4) Report from the chief surgeon, A. E. F., to the Surgeon General, U. S. Army, May 1, 1919. Subject: Activities of the chief surgeon's office, A. E. F., to May 1, 1919. On file, Historical Division, S. G. O.

(5) Report on the laboratory service of hospital centers in converted permanent buildings, undated, by Maj. Harrison S. Maitland, M. C. On file, Historical Division, S. G. O.

(6) Report of hospital center at Mesves, undated, prepared under the supervision of the commanding officer of the center (not dated or signed). On file, Historical Division, S. G. O.

(7) Report on the activities of the laboratory, Base Hospital No. 27, A. E. F., January 20, 1919, by the officer in charge of the laboratory. On file, Historical Division, S. G. O.

(8) Report of laboratory of Camp Hospital No. 15, A. E. F., April 1, 1919, by Capt. M. L. Holm, M. C. On file, Historical Division, S. G. O.

(9) Report on the laboratory situation in Third Army, by Lieut. Col. W. M. L. Coplin, M. C., March 18, 1919. On file, Historical Division, S. G. O.

(10) Report on mobile laboratories, A. E. F., undated, by Capt. C. O. Rinder, M. C. On file, Historical Division, S. G. O.

(11) Report on the laboratory service of the evacuation hospital, January 3, 1920, by Maj. Arthur U. Desjardine, M. C. On file, Historical Division, S. G. O.

(12) Report on the laboratory work of Mobile Hospital No. 1, A. E. F., by Capt. A. A. Johnson, M. C., officer in charge of laboratory, January 1, 1919. On file, Historical Division, S. G. O.

(13) Report on the laboratory work of Mobile Hospital No. 39, January 2, 1919, by First Lieut. William S. Keister, M. C. On file, Historical Division, S. G. O.

(14) Report on the laboratory service of divisional laboratories, A. E. F., undated, by Capt. Lucius A. Fritze, M. C. On file, Historical Division, S. G. O.

(15) Report on the pathological service, division of sanitation and inspection, American Expeditionary Forces, undated, by Colonel Louis B. Wilson, M. C. On file, Historical Division, S. G. O.

(16) Letter from director of U. S. Army Laboratory No. 1, to the chief surgeon, A. E. F., August 28, 1917. Subject: Post-mortem examinations. On file, A. G. O., World War Division, chief surgeon's files (321.630).

RETURN TO TABLE OF CONTENTS